Implications for recruitment Comparing urban and rural primary care PAs

By Kyle J. Muus, MA, Jack M. Geller, PhD, Richard L. Ludtke, PhD, Shihua Pan, PhD, Cathy Kassab, PhD, A.E. Luloff, PhD, L. Gary Hart, PhD

As recruitment and retention of physicians in sparsely populated areas becomes difficult, nonphysician providers-PAs, nurse practitioners, and certified nurse midwives-help fill the growing void left in such places by the scarcity of physicians. These professions were developed to expand the availability of primary health care services and to improve access to those services for underserved populations.¹

Although PAs continue to serve a supplemental function to physician care, they have an increasingly instrumental role to play in providing primary medical care; it has been suggested that PAs can substitute for physicians in 60% to 90% of primary care functions,²³ at lower cost.⁴ Because the largest specialty among rural physicians is family practice, the potential impact of PAs (and nonphysician providers in general) on rural health care is substantial.

In response to rising demand, the number of PAs is projected to increase by more than 70% by the year 2000, from 24,800 to approximately 40,000.⁵⁶ Estimates are that, today, every graduate of a PA program receives between five and nine employment offers.⁷⁸

Any reform of the nation's health care system is likely to transform the roles, responsibilities, and distribution of PAs-although to what degree has not been determined.⁹ Reform may, it has been suggested, cause rural areas to face even stiffer competition with urban areas for the services of nonphysician providers.¹⁰ Pending reform and vast increases in specialty and subspecialty PA training will inevitably cause rural areas to increase efforts to recruit PAs that have been trained in primary care fields.

Recruitment of PAs to rural areas is hampered by well-known barriers to nonphysician practice. These include state and federal regulations that obstruct reimbursement and prescriptive authority; excessive malpractice and liability premiums in some specialties; so-called gatekeeping behavior in organized medicine; and lack of understanding about the capabilities of PAs and other nonphysician providers.¹¹¹²¹³

An expanding body of literature has examined work satisfaction among nonphysician providers. Such studies have found that a number of variables correlate strongly with job satisfaction, including independence, challenging work, job security, colleague and supervisor support, and patients' acceptance of nonphysician providers. Documented reasons behind job dissatisfaction among nonphysician providers include heavy workload, underutilization, destructive competition, salary issues, few opportunities for advancement, incompatibility with a supervising physician or administrator, and inadequate scope of practice.^14151617

Some studies have highlighted these problems in rural areas. Documented sources of dissatisfaction among nonphysician providers in rural practice are listed in Table 1.^18192021

Responding to the expanding role of PAs in health care and the scarcity of research on PAs' practice location (that is, urban or rural), the AAPA and researchers from the University of North Dakota and the WAMI (Washington, Alaska, Montana, Idaho) Rural Health Research Center collaborated in late 1993 to conduct a nationwide study of PAs.

A random sample of 2,500 PAs was drawn from the AAPA membership database; 5 could not be surveyed because of an incorrect address listing. Two mailings of a questionnaire to each sample member yielded 1,560 respondents (response rate, 62.5%). Data collection began September 15, 1993, and concluded February 15, 1994.

Our primary interest was to obtain insights into similarities and differences between rural and urban practice across a range of issues. These included role delineation, job autonomy and other practice characteristics, decision making when choosing a practice location, and job satisfaction.

* Relevance of the sample Findings from this study are generalizable to AAPA members only, who constitute approximately 52% of PAs practicing in the United States.²⁶ Nonmembers were not included in the sampling frame.

To determine the extent to which our sample was comparable to the AAPA's member population, we conducted a series of intergroup comparisons across demographic and practice characteristics, using the AAPA's 1992 general census data.²⁷ Specifically, groups were compared by age, gender, race, education, status of practice (active or inactive), field of practice, years as a PA, state where practicing, and region of the country.

We determined that the sample contained a much larger percentage of PAs currently in practice (98.8%, compared to 85.4% of the universe of PAs). This overrepresentation is a likely source for observed differences across other factors, including gender, age, and job tenure. Underrepresentation of males in our sample is probably a function of having almost exclusively practicing PAs. Because older PAs tend to be male (the profession initially comprised mostly males, with a sizable percentage of military corpsmen),²⁸ they are less likely than their younger counterparts to still be in practice.

In addition, there appeared to be an overrepresentation of surgical subspecialists in the sample (22.4%, compared to 9.8% in the profession). Sample percentages were quite similar to AAPA percentages when compared for race, education level, practicing state, and national region.

* Defining "urban" and "rural" One of the main objectives of the study was to identify differences and similarities between PAs who practice in urban areas and those who practice in rural areas. To characterize the degree of rurality for practice location among PAs, we used the US Department of Agriculture's urban-rural continuum codes, which distinguish metropolitan ("metro" hereafter) counties by size and nonmetro counties by degree of urbanization or proximity to a metro area.²⁹

Metro areas are defined by the US Census Bureau as a county or group of counties that includes a city of at least 50,000 residents or an urbanized area with at least 50,000 residents that is itself part of a county or group of counties containing at least 100,000 residents. Nonmetro regions include all areas that are not designated as metro.

The Census Bureau's standard metro and nonmetro groupings are subdivided into four metro and six nonmetro categories to yield a 10-level county codification, from 0 (most urban) to 9 (most rural). This scheme allows for county data to be divided into refined residential groups, extending beyond metro and nonmetro comparisons, thereby allowing for analysis of trends in nonmetro areas that are related to population density and metropolitan influence.

We assembled the codes into four groups for our analysis:

• Codes 0, 1, 2, and 3 comprise PAs who practice in counties within metro areas.
  
• Codes 4 and 5 comprise PAs who practice in urbanized nonmetro counties (containing one or more cities with at least 20,000 residents).
  
• Codes 6 and 7 comprise PAs who practice in less urbanized, nonmetro counties (containing towns of 2,500 to 19,999 residents).
  
• Codes 8 and 9 comprise PAs who practice in thinly populated nonmetro counties (containing towns with fewer than 2,500 residents).
  

* Primary care breakdown Focusing on factors associated with recruitment of PAs into rural areas of the country, we sought to pinpoint how rural PAs differ from urban counterparts across a series of personal and practice-related characteristics. As noted, 88.1% of PAs in sparsely populated regions practice in a primary care-related field, compared to 43.4% of PAs in metro areas.

To improve the delineation of true urban-rural differences, we controlled for specialty-induced variation by including in our analyses only PAs who were practicing within a primary care field. Our definition of "primary care," consistent with what is used by the AAPA to track PA practice,³⁰ included family practice, general internal medicine, general pediatrics, general obstetrics and gynecology, and emergency medicine.

Because primary care services are, obviously, provided in urban and rural areas nationwide, PAs trained in primary care can choose to practice in either setting. Subspecialty-trained PAs, however, almost assuredly practice in urbanized settings because their services are not in demand in most rural health care facilities. Exclusion of subspecialty practitioners from this study, therefore, is warranted because they have few significant implications for rural PA recruitment.

Given that approximately 18% of PAs practice in towns of 10,000 or fewer residents,³¹ we expected small group sizes among nonmetro PAs. To offset this problem, we oversampled this group and added information about them to the database.

The AAPA provided names and addresses of all member PAs (n = 2,077) who practiced in communities of 10,000 or fewer residents and who had not been selected in the first sample. Of PAs surveyed in this oversample, 7 could not be contacted because of incorrect address. A total of 1,391 (67.2%) completed questionnaires were returned. Data collection began October 1, 1993, and concluded on February 15, 1994.

Of these 1,391 PAs, 253 were excluded from the database because they were not practicing in a primary care specialty. Of the remainder, 354 PAs were excluded because they were practicing in a metro or an unspecified area. The appearance of some metro PAs in this group was expected because some have relocated from a rural to an urban region and because others fit the AAPA definition of rural (communities of 10,000 or fewer residents) but not our definition of rural (nonmetro counties). The resulting number of usable oversample respondent questionnaires was 784.

Before it was combined with the oversample information, original sample data were cleaned. Of those 1,560 respondents, 766 were removed because they did not practice in primary care; 44 were excluded because the location of their practice (county) was unspecified. Combining the usable data from respondents in the first (n = 750) and second (n = 784) samples resulted in a group size of 1,534 primary care PAs.

* Univariate analysis Among the 1,560 respondents in the initial random sample, 50.5% were female; 67.2% said they were married. Mean age was 37.2 years (range, 24 to 68). The majority (96.3%) said they practiced full-time. Mean duration of practice was 7.3 years.

In addition, 56.5% of respondents said they currently practiced in a specialty or subspecialty (eg, pediatric AIDS, cardiothoracic surgery); the rest practiced in a primary care field (family medicine, 31.7%; emergency medicine, 8.3%; general internal medicine, 7.0%; obstetrics and gynecology, 3.2%; general pediatrics, 1.6%). The most commonly reported work settings were group office (32.5%), teaching hospital (25.1%), nonteaching hospital (13.3%), solo practice (13.2%), and health maintenance organization (7.8%).

Among respondents, 76.0% reported currently practicing in a large metro area; 24.0% practiced in a nonmetro region. Of the latter percentage, 13.3% practiced in a thinly populated region (a county containing no towns with more than 2,500 residents).

Figure 1, page 51, illustrates the division of PA field of practice by location of practice. Clearly (and not surprisingly), the percentage of PAs in specialty practice decreased as rurality of practice increased. Results indicated that PAs in the most rural areas practiced almost exclusively in primary care.

FIGURE 1

Primary care and specialty practice by location
Click here to view full-size graphic

* Practice characteristics and job autonomy Polled PAs were asked a series of questions about attributes of their practice and their degree of job autonomy (see Table 2, page 52). Analyzing the combined sample, we found no differences in the length of the work week: PAs uniformly reported practicing approximately 40 hours a week, irrespective of setting (urban or rural).

We did find, however, that weekly on-call hours increased substantially as rurality increased (see Figure 2, page 57). PAs who practiced in sparsely populated, nonmetro counties reported two to three times more call hours than those who practiced in more densely populated areas. We expected this: Rural PAs are more likely than urban PAs to be the exclusive health care provider in an area.

FIGURE 2

Weekly working and on-call hours
Click here to view full-size graphic

The number of weekly outpatient visits was inversely related to rurality; between-group differences were statistically significant. These differences dissipated, however, when hourly outpatient visits were examined.

We also noted significant differences in the number of weekly inpatient visits across urban and rural groups. The relationship between these visits and rurality of practice locale was not, however, linear. PAs tended to report eight or nine inpatient visits a week-with the exception of PAs from urbanized nonmetro areas, who reported, on average, 2.66 visits a week. This is probably a function of the fact that this group had the lowest percentage (11.8%) of PAs practicing in hospitals or nursing homes, the settings where inpatient visits typically occur. We found similar results when inpatient visits per hour were investigated (see Table 2).

We were not surprised to find that primary care PAs in rural areas participated in a wider variety of activities in the course of their practice than did their urban counterparts (see Figure 3, page 58). When polled PAs were asked to indicate, from a list of 19 clinical activities, how many they participated in at least once a month, the mean number increased incrementally with a corresponding increase in rurality. Between-group differences were statistically significant (P = .0000).

FIGURE 3

Variety of clinical activities
Click here to view full-size graphic

Results indicate that rural-based PAs spent much more practice time away from the supervising physician. The percentage of PAs who worked in the same health care facility as their supervisor declined as rurality of practice increased. Furthermore, the mean weekly hours that a PA worked directly with the physician was inversely related to degree of rurality.

We found that rural-based primary care PAs possessed a greater degree of practice autonomy, compared to urban PAs, when other measures of independence were examined (see Table 1). The practice conditions that rural PAs were more likely to report in this regard are listed in Table 3, page 60.

* Satisfaction with work We also assessed the degree of satisfaction that respondents reported in various aspects of practice. Rural PAs had a significantly higher level of satisfaction with professional acknowledgement and respect from nurses, patients, and community residents. Rural PAs were also less satisfied than urban PAs with the number of other PAs in the community, the availability of the supervising physician, the level of work-related stress, and the amount of time off.

No significant urban-rural differences were noted across the following aspects of practice: satisfaction with the relationship with the supervising physician; quality of care provided by the supervising physician; salary; degree of responsibility and autonomy; range of services PAs are allowed to provide; workload; opportunities for continuing medical education (CME); and professional acknowledgment and respect from the supervising physician, other physicians, and other PAs.

* Choosing a practice location Earlier we noted that the role of PAs in rural primary care has expanded in recent years, making issues of PA recruitment and retention in rural areas increasingly important. To address these issues, respondents rated the degree of importance they placed on an array of factors when they chose the location of their current practice.

Rural-based PAs, we found, placed significantly more importance than urban PAs did on a considerable degree of autonomy, prescriptive authority, a state with favorable reimbursement policies, and quality of public schools. Rural PAs assigned substantially less importance than urban PAs did to good opportunities for CME, proximity to family, comprehensive hospital facilities, access to quality laboratory services and other types of technology, presence of other PAs in the area, salary, and comprehensive benefits. No meaningful differences were found between rural and urban PAs among issues of reputation and character of the supervising physician or fulfillment of loan obligations.

Scant research on PAs has gone beyond simple univariate and bivariate analyses of personal and practice characteristics. To address this limitation, we designed a study that would allow us to draw urban and rural distinctions across a series of issues, including role delineation, job autonomy, decisions about selecting a practice location, and job and community satisfaction. In identifying and describing a number of significant differences between urban- and rural-based PAs, our findings are not only informative but have meaningful implications on the recruitment of PAs in rural, underserved regions.

Clearly, prescriptive authority is a privilege that facilitates PA practice in rural areas. Indeed, states with the most liberal prescriptive practice regulations have the most PAs³² and the highest percentage of PAs working in rural areas.³³ Our results reveal that, compared to urban PAs, rural respondents placed substantially more importance on this privilege when choosing a location in which to practice.

(Note: In 1993, 15 of 50 states did not authorize PAs to prescribe; a 12-state cluster of these 15 states along the Mississippi River contained approximately 37% of the nation's areas of rural health professional shortages.³⁴³⁵ Passage and implementation of state-based legislation on prescriptive privileges could be expected to enhance recruitment of PAs in these underserved areas.)

Another issue that we found to be of great importance to rural PAs is favorable reimbursement policies. Because state-to-state variability in laws regarding compensation and Medicaid reimbursement affects PA deployment,³⁶ efforts should be directed toward modifying state policies to compensate these providers adequately.

Results of this study showed that certain benefits are associated with rural PA practice. One positive aspect was public acceptance: Rural PAs were significantly more satisfied than their urban counterparts with the amount of respect and consideration given by nurses, patients, and members of the community at large. Such information should be made available to students in PA programs to encourage rural preceptorships and practice.

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